Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
55 residents
Based on a January 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 55
Deficiencies: 1
Jan 31, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to manage their financial affairs, specifically regarding access to funds on weekends and evenings.
Findings
The facility failed to ensure residents had access to their funds during weekends and evenings, potentially affecting 34 residents. Interviews with residents and staff revealed uncertainty and lack of procedures for obtaining funds outside regular business hours.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents had access to funds on weekends and evenings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 34
Facility census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Interviewed regarding access to funds on weekends | |
| State Tested Nurse Aide (STNA) #10 | Interviewed about procedures for obtaining funds when BOM is not present | |
| Registered Nurse (RN) #12 | Interviewed about knowledge of access to funds on weekends and evenings | |
| State Tested Nurse Aide (STNA) #14 | Interviewed about how residents get funds if BOM is not present | |
| Registered Nurse (RN) #20 | Interviewed about resident requests for funds after hours |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 4
Dec 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to administer intravenous (IV) fluids per professional standards, specifically allowing an unlicensed company to administer dangerous IV fluid medications to residents.
Findings
The facility failed to ensure that IV fluids were administered safely and appropriately by allowing Agency #700, which was not licensed by the Ohio State Pharmacy Board, to administer IV medications to residents. This affected multiple residents and represented a past noncompliance that was corrected prior to the survey. Additionally, the facility failed to follow infection control procedures during a wound dressing change for one resident.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146750.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility allowed an unlicensed company (Agency #700) to administer dangerous IV fluid medications to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services that assure accurate acquiring, receiving, and dispensing of drugs due to use of unlicensed company for IV fluids. | Level of Harm - Minimal harm or potential for actual harm |
| Governing body failed to appropriately manage the facility by allowing an unlicensed company to administer IV fluids. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow infection control procedures when a staff member did not wash or sanitize hands after removing gloves during a wound dressing change. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents receiving IV fluids through Agency #700: 36
Facility census: 56
Additive volume: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse #300 | Regional Nurse | Interviewed regarding use of unlicensed Agency #700 and confirmed lack of Ohio State Pharmacy Board license. |
| RN #10 | Registered Nurse | Observed and interviewed regarding failure to wash or sanitize hands after glove removal during wound dressing change. |
| [NAME] President of Operations #305 | President of Operations | Received education regarding proper pharmacy licensure and confirmed education was provided. |
| Director of Operations #310 | Director of Operations | Received education to ensure TDD licensure for Ohio is effective before accepting medication into facility. |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 9
May 27, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, transfer and discharge notifications, bed hold policies, notification of significant changes in condition, nutritional needs, food safety, medical record accuracy, and environmental safety in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure physician signature on advanced directives, failure to provide timely transfer/discharge notices and bed hold notices, failure to notify appropriate authorities of significant resident condition changes, failure to follow menu portion sizes, failure to dispose of expired food, inaccurate resident code status documentation, and unsafe environmental conditions such as damaged walls and missing handrails.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure the physician signed a resident's formulated advanced directive. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a resident with transfer or discharge notices and failed to send a copy to the Ombudsman. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written bed hold notices to a resident discharged to the hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify the state mental health authority when a resident with mental illness had a significant change in condition and was admitted to hospice. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure menu spreadsheet and recipes for portion sizes were followed, specifically for scrambled eggs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to dispose of expired food out of active circulation, including expired bread and milk. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident's medical record accurately reflected the resident's code status. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe and comfortable environment by not properly repairing a damaged wall and broken railing in a resident room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure handrails were maintained in a safe manner to allow residents to utilize them; missing handrail with nails sticking out. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 46
Residents affected: 1
Residents affected: 1
Residents affected: 46
Residents affected: 25
Portion size: 3
Portion size: 2
Expired bread loaves: 16
Expired milk: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director #59 | Social Services Director | Verified deficiencies related to advanced directives, notification of significant change, and code status |
| Dietary Manager #48 | Dietary Manager | Observed and verified portion sizes and expired food in kitchen |
| Administrator | Administrator | Verified deficiencies related to transfer/discharge notices, bed hold notices, environmental safety including damaged walls and missing handrails |
| Dietary Technician | Dietary Technician | Provided information on proper preparation of scrambled eggs |
Inspection Report
Annual Inspection
Deficiencies: 4
Feb 19, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, care planning, assessment accuracy, and medication regimen reviews at Locust Ridge Healthcare LLC.
Findings
The facility was found to have environmental safety issues including cracked windows, leaks, and makeshift curtains in several resident rooms and activity areas. Additionally, the facility failed to accurately assess a resident's status regarding physical restraints, did not timely develop comprehensive care plans for a resident, and failed to conduct monthly medication regimen reviews for another resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, comfortable, and homelike environment including issues with cracked windows, leaks, and sheets used as curtains affecting seven rooms and activity areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess a resident's status on physical restraints, resulting in incorrect coding on the Minimum Data Set (MDS). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely develop and implement comprehensive care plans within the required timeframe for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct monthly medication regimen reviews for one resident for multiple months. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents reviewed: 12
Residents reviewed: 12
Residents reviewed: 5
Months missed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director (MD) #184 | Verified environmental issues including leaks and broken windows |
| Regional Clinical Consultant | Regional Clinical Consultant (RCC) #169 | Verified environmental issues and incorrect MDS coding |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) #160 | Interviewed regarding physical restraint status of Resident #32 |
| Director of Nursing | Director of Nursing (DON) | Verified no physical restraints on Resident #32 and lack of medication reviews |
| Registered Nurse | Registered Nurse #180 | Verified absence of comprehensive care plans for Resident #42 |
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